Delayed decompression for cauda equina syndrome secondary to lumbar disc herniation: long-term follow-up results

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1 J South ed Univ, 0, (): - doi 0./j.issn Original Article Delayed decompression for cauda equina syndrome secondary to lumbar disc herniation: long-term follow-up results LAI Xunwei *, LI Wei *, WANG Jixing, ZHANG Huijian, PENG Hongmei, YANG Dehong Department of Spinal Surgery, Department of Urinary Surgery, Nanfang Hospital, Southern edical University, Guangzhou 0, China Abstract: Objective To assess the impact of delayed decompression on long-term neurological and bladder function recovery in patients with cauda equina syndrome (CES) secondary to lumbar disc herniation (LDH). ethods The clinical data of patients receiving delayed decompression surgery for CES secondary to LDH were reviewed. The bladder function, bowel control, sexual ability and neurological functions of the lower limbs were evaluated after the operation, and the urodynamic changes were assessed in patients with urodynamic data before and after the operation. Results Surgical decompression was performed at.±. weeks in patients with complete CES and at.±. weeks in patients with incomplete CES after the onset of symptoms. The patients were followed up for a mean of.0±. months (-0 months). In the patients with incomplete CES, obtained full recovery, had slight sensory alterations in the saddle area or the lower limbs. In the patients with complete CES, had full recovery, reported slight sensory alterations in the saddle area or the lower limbs (including with occasional constipation); still had sense deficit in the saddle area and difficulties in bladder or bowl ing, but they all reported significant improvements compared to the condition before operation. Urodynamic analysis in the patients with preand postoperative urodynamic data showed increased abdominal pressure when voiding with significantly reduced residual urine in all the patients; patients with abnormal first desire volume before operation reported recovery after the operation. Conclusion Patients with LDH-induced CES who missed the chance of early decompression can still expect favorable functional recovery in the long term. The improvement of bladder function following decompression is probably a result of recovery of bladder sensation and the compensation by increased intra-abdominal pressure. The key strategy to promote bladder function recovery in these patients is to promote the detrusor recovery. Keywords: cauda equina syndrome; lumbar disc protrusion; bladder function; urodynamics INTRODUCTION Cauda equina syndrome (CES) is a rare condition arising from severe compression of the cauda equina to cause such symptoms as saddle and/or genital sensory disturbance and/or sexual, bladder and bowel dysfunctions []. Around 0%-0% of patients have urinary retention (CES-R), and 0%-0% have an incomplete syndrome []. In complete CES is characterized by partial urinary difficulties including weak urinary sensation, loss of desire to void and poor urinary stream, and the patients often have unilateral or partial saddle and genital sensory deficits with retained trigone sensation. CES-R (or complete CES) is characterized as painless urinary retention and overflow incontinence with extensive saddle and genital sensory deficits and deficiency of trigone sensation []. Lumbar disc herniation (LDH) is a common cause of compression of the lumbar nerve root or cauda equine, resulting in such symptoms as low back pain, sciatica, leg weakness and sensory alteration. For patients with CES caused by LDH, prompt decompression is required to avoid permanent function loss, and h or even h after the onset of CES is thought Received: 0-0- Accepted: Correspondence author: YANG Dehong, D, PhD, drmyang@yahoo.com. to be the golden time for surgical intervention [, ]. But according to some reports, delayed decompression (mean. days) after the onset of CES also achieved good outcomes [-]. The consequences of further delayed decompression (by weeks or even months) remain undefined. In this study, we analyzed the long-term outcomes of patients with CES secondary to LDH who underwent delayed surgical decompression and evaluated the long-term consequences of delayed surgical intervention. PATIENTS A ETHODS We reviewed the data of consecutive patients with CES secondary to LDH (CES-LDH) treated in Nanfang Hospital from 00 to 0. The diagnosis of CES-LDH was established based on the following criteria: (a) presence of symptoms of the bladder with or without sexual or bowel dysfunctions; (b) abnormal muscle strength and sensation related to the compressed nerve, alterations of saddle sensation and anal squeeze pressure, and decreased penilo-cavernosus reflexes (in men); (c) sexual dysfunction in men in terms of morning erection revealed by questionnaire; and (d) severe disc herniation or spinal canal stenosis confirmed by magnetic resonance imaging (RI) or computed tomography (CT). In this study, we made the diagnosis of complete

2 J South ed Univ, 0, (): - CES when the patients had any of the following symptoms: urine retention or incontinence, uncontrolled defecation, and penile erectile dysfunction. Incomplete CES was defined as partial loss of functions of the bladder, bowel or sexual activities. The follow-up interviews were conducted in a cross-sectional manner, in which the patients were surveyed for their current general life, motor and sensory functions of the lower limbs, and urinary, bowel and sexual functions. Six patients with complete CES before operation received urodynamic analysis both before and after operation. RESULTS Out of interviewed patients with the diagnosis of LDH-CES, responded to the survey, including patients who completed the survey in the physician's office and patients receiving the interview on the phone. The patients had a mean age of. years (ranging from to 0 years) at the time of operation and the mean follow-up time was.0 ±. months (-0 months). A diagnosis of complete CES was established in of the patients, including patients requiring catheterization for urine drainage and patients with loss of control of urination or defecation, or both; patients did not have morning erection and could not finish sexual intercourse. Physical examination of the patients revealed multiple positive signs (Tab.). Eleven of the patients had the history of low back pain. In patients, CES symptoms occurred immediately after chiropractic manipulations (type II CES according to Tandon and Sankaran) [], and in patient, uncontrollable urination and defecation occurred after a long motorcycle ride on rough roads. Eleven patients had LDH at the level of L /, including patient with also L /S LDH; LDH at L /S was found in patient. Tab. Results of functional examinations in patients with complete CES before operation Patient No. Age (year) Perineal sense Bladder Bowel control Penile erection Spinal level otor () and sense (S) in legs* Time of operation Complete Loss months Intact days months 0 weeks weeks : IV; S: weeks days : I; S: days 0 : ; S: days 0 : IV; S: months days 0, L/S : III; S: days lost, L/S : ; S: days L/S months days,, and indicate slight, moderate and severe reduction, respectively. *The roman numbers indicate the grade of muscle strength. : Not recorded; : Not applicable. The patients with complete CES received delayed surgical decompression from days to months (mean. weeks) after the onset of symptoms. Full surgical decompression was performed in cases in our department by senior surgeons specialized in spinal surgery; patient was transferred to our department after operation in a local hospital with poor recovery, but the decompression was satisfactory as confirmed by RI scan. The patients reported good recovery or significant improvement from days to 0 months after operation (Tab.). In this group, (0% ) patients reported good recovery ( with full recovery and only had sensory alterations in the saddle area or lower limbs), and patients still had sense deficits in the saddle area and difficulties in bladder or bowl or both, but none of them required catheterization in spite of occasional incontinence of defecation or urination. Twenty-three of the patients were diagnosed to have incomplete CES before surgery. Full decompression was performed at days to months (mean. weeks) after the onset of symptoms (including numbness or tingling in the saddle area, reduced erectile time or sexual desire, slow start and prolonged void time of urination, constipation, and reduced pressure for defecation). Thirteen of the patients had L / LDH, patients had L or S disc herniation, patient had herniation at both levels, and patient had herniation at L / and L /. In all the patients, the condition did not evolve into complete CES before operation (Tab.). Nine of the patients received chiropractic manipulation before the onset of CES. In follow-up, (% ) patients had full recovery, and (% ) patients still had mild sensory abnormalities in the saddle area or the lower limbs (Tab.).

3 J South ed Univ, 0, (): - Tab. Results of functional examinations in patients with complete CES after decompression Patient Time after Perineal Penile otor () and Bladder Bowel No. operation (month) sense erection sense (S) in legs* Often incontinence constipation occ. constipation : IV; S: S: : III; S: : III; S: :; S: :IV; S: :III; S: :; S:,, and indicate slight, moderate and severe reduction, respectively. Occ: Occasional; : Not applicable. Tab. Results of functional examinations in patients with incomplete CES before operation Patient No. Age (year) Perineal sense Bladder Bowel Penile erection Spinal level otor () and sense (S) in legs* Timing of operation L/S : ; S: days : L I; S: month /S : L III; S: 0 days : ; S: days L/S : ; S: month L/S : ; S: weeks : ; S: months : ; S: months L/S : ; S: months 0 L/S : ; S: days : ; S: months : ; S: days : ; S: months : ; S: days L/S : ; S: days : ; S: month 0 :III; S: month days :IV; S: days L/S days 0 :; S: days 0 L/S :; S: days L// :II; S: days :IV; S: months days Urodynamic analysis was performed in patients with complete CES (Tab.). At to (. ±.) months after the operation, residual volume reduced significantly in all the patients and to the normal level in patients. The peak flow rate increased in patients. Contractions of intra-urethral sphincter demonstrated by urethral pressure were normal or reduced before operation, and became normal in the follow-up in all the cases. The most significant finding was the sensory function of the bladder, as we found that the first-desire volume was in the normal range in all the patients after the operation. But the detrusor contraction still remained paralyzed except in one patient who showed weak contraction during voiding. The non-inhibitory contraction collaborated by the detrusor and autonomic nerves were absent in all the patients. Strong intra-

4 J South ed Univ, 0, (): - Tab. Results of functional examinations in patients with incomplete CES after decompression. Patient No. 0 0 Time after operation (month) 0 0 Age (year) 0 0 Perineal sense tingling Bladder Bowel : Not detected (because the patients answered the phone call only without showing up personally). Penile erection otor () and sense (S) in legs : ; S: : ; S: Numbness abdominal pressure was detected in all the patients during voiding. DISCUSSION The occurrence of CES caused by LDH can be either gradual or sudden. In slowly developing CES, the symptoms evolve progressively and sustain over a long period of time as in the case of incomplete CES, whereas in the acute type, complete CES can occur in seconds. In our study, out of the patients with complete CES reported a history of low back pain, patients developed complete CES shortly after chiropractic manipulation, patient developed complete CES in days after chiropractic manipulation, and developed complete CES after a long motorcycle ride. In the patients with incomplete CES, progression of the condition was gradual, and patients reported worsening of the condition after chiropractic manipulation. As a common therapy for back pain associated with muscle strain, chiropractic manipulation should be performed with caution after careful examination to exclude such contraindications as LDH, tuberculosis, and tumors. In patients with CES, neurological deterioration occurs in a progressive manner [0, ]. If the patients' condition allows, surgery should be performed as soon as possible to prevent neurological deterioration [-] and promote recovery of the neural functions. According to Ahn et al [], decompression within h after the onset of CES could achieve favorable outcomes, but sooner (within h) surgical intervention did not significantly improve the patients' outcomes; Kohles et al [] and Delong et al [], however, believed that surgical intervention of CES within h could bring further benefit. In our case, all the patients received much delayed decompression (mean. weeks for complete CES and. weeks for incomplete CES). Six (0% ) of the patients with complete CES achieved good recovery and the other also reported significant improvement after surgery, and patients with incomplete CES all had normal life after delayed decompression. Several reasons might explain the functional recovery of the patients after delayed decompression for CES. Firstly, in slowly developing CES, the compressed nerve roots may slowly develop tolerance to hypoxic conditions and still retain the potential of functional recovery after delayed compression; secondly, as peripheral nerves, the cauda equina nerves possess regeneration ability and may recover from reversible injuries caused by compression, which also explains the better results of early decompression than delayed decompression, especially in terms of bladder and bowel functions. During the surgery, we found that the cauda equina roots were swollen with a reddish purple color, but it could be difficult to accurately assess the damages without histopathological evidence. The injury of the cauda equine roots is not necessarily irreversible when

5 J South ed Univ, 0, (): - Tab. Comparison of urodynamic findings in patients with complete CES before () and after () the operation Findings No. No. No. No. No.0 No. Gender F F Age of diagnosis (year) 0 Peak flow rate (ml/s) Residual volume (ml) Urethral pressure Bladder filling first sensation (ml) First desire (ml) Urination urgency (ml) 0 0 aximum bladder volume (ml) Intra-abdominal pressure (cm HO) 0 0 Urethremphraxis Detrusor contraction During voiding Non-inhibitory contraction The case No. assigned to the individual patients in Tab. and is used consistently this table.,, and indicate slight, moderate and severe reduction, respectively. patients receive late decompression. In addition, progression of incomplete CES into complete CES occurred in none of our cases even after months' delay of decompression. Thirdly, this long-term follow-up study allowed assessment of neural functional recovery of the patients long after the operation. Chang et al [0] followed patients with CES for. years and found that the long-term outcome of the patients was not necessarily poor in cases of poor short-term recovery of bladder function [0], which was also supported by the results of similar studies [, ]. An important finding of this study is that in patients who reported recovery of urination, their recovery was far from good as indicated by the results of urodynamic analysis. This discrepancy had been noticed before, and the bladder function can be disturbed seriously even in the patients without symptoms []. Our results of urodynamic analysis indicate that although the detrusor remained paralyzed, the recovered sensation of the bladder and the compensation by increased intra-abdominal pressure allowed the patients to finish urination. This highlights the importance of training the patients to practice the skills of increasing the intraabdominal pressure (Valsalva maneuver), which serves as one of the rehabilitation strategies for these patients. Although the patients with CES can have favorable motor function recovery of the lower limbs [,, ] (as we also found in our patients) and achieve significant regeneration of the neuromuscular junctions even after denervation for up to one year [], the recovery of detrusor function remained poor in these patients. The relations among the recovery of bladder sensation, motor function of the extremities and detrusor remain so far unclear, but this might point the direction of further study. In conclusion, we believe that patients with LDH- CES who missed the chance of early decompression can still expect favorable functional recovery in the long term. The improvement of bladder function following decompression is probably a result of recovery of bladder sensation and the compensation by increased

6 J South ed Univ, 0, (): - intra-abdominal pressure. The key strategy to promote bladder function recovery in these patients is to promote the detrusor recovery, and long-term follow-up of the patients is of critical importance. Nevertheless, we could not accurately evaluate the benefit of delayed decompression surgery for ethical reasons, and further study is warranted to address this issue. REFERENCES: []a B, Wu H, Jia L, et al. Cauda equina syndrome: a review of clinical progress[j]. Chin ed J (Engl), 00, (0): -. []Gardner A, Gardner E, orley T. Cauda equina syndrome: a review of the current clinical and medico-legal position[j]. Eur Spine J, 0, 0(): 0-. [] Kohles SS, Kohles DA, Karp AP, et al. Time-dependent surgical outcomes following cauda equina syndrome diagnosis: comments on a meta-analysis[j]. Spine, 00, (): -. [] Delong WB, Polissar N, Neradilek B. Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies[j]. J Neurosurg Spine, 00, (): 0-0. [] Girardi FP, Cammisa Jr FP, Huang RC, et al. Improvement of preoperative foot drop after lumbar surgery[j]. J Spinal Disord Tech, 00, (): 0-. [] Fraser S, Roberts L, urphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation[j]. Arch Phys ed Rehab, 00, 0(): -. [] Dhatt S, Tahasildar N, Tripathy SK, et al. Outcome of spinal decompression in cauda equina syndrome presenting late in developing countries: case series of 0 cases[j]. Eur Spine J, 0, 0(): -. [] Tandon PN, Sankaran B. Cauda equina syndrome due to lumbar disc prolapse[j]. Indian J Orthop,, (0):. [] Germon T, Ahuja S, Casey AT, et al. British Association of Spine Surgeons standards of care for cauda equina syndrome[j]. Spine J, 0, (): S-. [0]Todd NV, Dickson RA. Standards of care in cauda equina syndrome [J]. Brit J Neurosurg, 0, 0(): -. []ackenzie SJ, Smirnov I, Calancie B. Cauda equina repair in the rat: part. Time course of ventral root conduction failure[j]. J Neurotraum, 0, (): -0. []Kumar JR, Krishnan RU, enon K. Timing of surgery in cauda equina syndrome[j]. Amrita J ed, 0, : -0. []Gooding BW, Higgins A, Calthorpe DA. Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome [J]? Brit J Neurosurg, 0, (): -. []Todd NV. Cauda equina syndrome: findings on perineal examination [J]. Brit J Neurosurg, 0, ():. []Korse NS, Jacobs W, Elzevier HW, et al. Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review[j]. Eur Spine J, 0, (): 0-. [] Chau AT, Xu LL, Pelzer, et al. Timing of surgical intervention in cauda equina syndrome: a systematic critical review[j]. World Neurosurg, 0, (): 0-0. []Aly TA, Aboramadan O. Efficacy of delayed decompression of lumbar disk herniation causing cauda equina syndrome [J]. Orthopedics, 0, (): e-. []Bydon, Gokaslan ZL. Time to treatment of cauda equina syndrome: a time to reevaluate our clinical decision[j]. World Neurosurg, 0, (): -. []Sonntag VK. Why not decompress early? The cauda equina syndrome [J]. World Neurosurg, 0, (): 0-. [0]Chang HS, Nakagawa H, izuno J. Lumbar herniated disc presenting with cauda equina syndrome: long-term follow-up of four cases[j]. Surg Neurol, 000, (): 00-. []Foruria X, de Gopegui KR, García-Sánchez I, et al. Cauda equina syndrome secondary to lumbar disc herniation: Surgical delay and its relationship with prognosis[j]. Rev Esp Cir Ortop Traumatol, 0, 0(): -. []Hellström P, Kortelainen P, Kontturi. Late urodynamic findings after surgery for cauda equina syndrome caused by a prolapsed lumbar intervertebral disk[j]. J Urol,, (): 0-. []Aono H, Nagamoto Y, Tobimatsu H, et al. Surgical outcomes for painless drop foot due to degenerative lumbar disorders[j]. Clin Spine Surg, 0, (): E-. []Wang Y, Nataraj A. Foot drop resulting from degenerative lumbar spinal diseases: clinical characteristics and prognosis[j]. Clin Neurol Neurosur, 0, : -. []Wu P, Chawla A, Spinner RJ, et al. Key changes in denervated muscles and their impact on regeneration and reinnervation[j]. Neural Regen Res, 0, (0):. 赖勋维 *, 李威 *, 王吉兴, 张辉见, 彭红梅, 杨德鸿 南方医科大学南方医院脊柱外科, 泌尿外科, 广东广州 0 摘要 : 目的分析腰椎间盘突出伴马尾神经综合征患者接受延迟手术减压后神经系统及排尿功能恢复的长期随访结果 方法将 例符合腰椎间盘突出伴马尾神经综合征患者纳入此次随访, 着重关注患者术前及术后的膀胱排空功能 排便功能 性功能 鞍区感觉及下肢神经功能恢复情况 ; 例患者术前术后均接受尿动力学检查 结果 例患者中, 例完全性马尾神经综合征患者平均延迟手术减压时间为.+. 周, 例不完全性马尾神经综合征患者平均延迟减压时间为.+. 周 ; 所有患者随访 ~0 月 ( 平均.0+. 月 ) 例不完全性马尾神经综合征患者中, 例完全恢复, 例存在轻微的鞍区或下肢感觉功能改变 ; 例完全性马尾神经综合征患者中, 例患者完全恢复, 例患者存在轻微鞍区或下肢感觉障碍且其中 例存在偶发便秘, 其余 例患者存在不同程度的鞍区感觉障碍 排尿及排便功能障碍 例有完整术前及术后尿动力学结果的患者中, 随访尿动力学检查提示排尿时腹压明显上升, 残余尿量较术前明显减少, 其中 例患者初次排尿感觉时膀胱容量恢复正常 结论对接受延迟手术的腰椎间盘突出伴马尾神经综合征患者, 长期随访结果显示多数患者预后良好, 神经功能均有不同程度恢复 尿动力学检查提示膀胱排空功能恢复可能为膀胱感觉恢复引发的排尿时腹内压代偿升高所致 膀胱功能恢复的关键策略为促进膀胱逼尿肌收缩功能的恢复 关键词 : 马尾神经综合征 ; 腰椎间盘突出 ; 膀胱功能 ; 尿动力学 收稿日期 :0-0- 作者简介 : 赖勋维, 硕士, david@live.com; 李威, 博士, 0@qq.com 赖勋维 李威共同为第一作者通信作者 : 杨德鸿, 主任医师, 副教授, 硕士生导师, drmyang@yahoo.com